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CONVERGE <br /> California Medical Waste Tracking Document (877) 773-0440 Phone:(408)436-2000 ❖ Fax:(408)538-3111 <br /> 24 HRS EMERGENCY PHONE:(408)436-2000 <br /> 1430 Koll Circle Suite 103 ❖ San Jose CA 95112 TRANSPORTER PERMIT <br /> aeneratOr'S information: Account Number: 299199 <br /> Generator Deuel Vocational Institution (DVI) <br /> Contact: Lisa M.Rocha TRANSPORTER PERMIT# 5961 <br /> CA E.P.A.LICENSE# CAL000358901 <br /> Street: 23500 Kasson Road Telephone: 209-835-4141 Ext 5432 <br /> City: Tracy State: CA Zip: 95376 Pick-up Frequency: WKLY-WED LATE AM CA D.O.T. PERMIT# 409099 <br /> Driver Route No: SP100 Manifest Number: 13-0821-3A Building: <br /> Time Arrived: Time Departed: v <br /> ❑ Pharmaceuttcat Waste *Check box for waste type <br /> Waste Collected:UN3291 Regulated Medical Waste rl 6.2 PGII UN 3291,Regulated Medical Waste(Red bags,Sharps&Vet Waste r <br /> TTs777 <br /> Tuh# Tuh# Tub# Tuh# Tub# Tuh# Tub# Tub# Tuh# Tub# Tub# Tub# <br /> Size Size Size Size Size Site Sita Size SizeSize Size Size Sizelbs lbs lbs lbs bs lbs hs lbs bs Ihs lbs Tub#Tub# Tub# Tub# <br /> Tub# a Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tuh# Tub# Tub# Tub# <br /> Sit, Site Size Size Site Size Size Site Site Size Size Size Site Size Size Size <br /> Size <br /> lbs lbs lbs lbs <br /> lbs lbs lbs lbs lbs lbs Tub# <br /> lbs lbs lbs lbs lbs Ihs lbs Tub# Tub# Tub# <br /> Tub# Tub# Tub# Tub# Tub# TlTuh# Tub# TlTub# Tub# Tub# Tub# <br /> Size Size Size Size Size Size Size Size Size Size Size Ib Ib lbs lbs Size Size Size Size Size <br /> 110, lbs <br /> Size <br /> lbs Ihs <br /> s <br /> Ihs lbs lbs lbs @ lbs <br /> lbs lbs „ ,- <br /> e <br /> TLhTAIzWEJGHT' <br /> g, Y Ti)TpOTAVV <br /> 1NIGNT .. : <br /> Ia T k lbs .,., u. ... <br /> s., .7A .u, .., ..n _ ., <br /> Fed-Bag,Sharps,Chemotherapy&Pharmaceutical Waste must be segregated and stored in separate containers.Each waste stream must be recorded separately on this manliest. <br /> SHARPS CONTA/NER/s DELIVERED PHARMA CONTA/NER/s DELIVERED <br /> RED-DAG CQNTA/ ER/s DELIVERED Qct iZon', 4T'►`7 <br /> 77 <br /> r �Desdrl Tton s <br /> c 1pto .._ 2n! IteIn,ID',, p. <br /> SHARPS-50T S-QUARTS DISPOSABLE SHARPS CONTAINER PW-2GAL 2.GAL PHARMA CONTAINER(RED) <br /> 8I0-32GAL 32-GALLON RED-BAG WASTE COLLECTION CONTAINER PWBGAL B GAL PHARMA CONTAINER(RED) <br /> SHARPS-1 QT 1-QUARTS DISPOSABLE SHARPS CONTAINER <br /> Signatures for Compliance and Authorizations: `- <br /> AS A REPRESENTATIVE OF THE ABOVE FACILITY,I CERTIFY THAT THE CONTENT OF THIS CONSIGNMNET WASTE ARE FULLY AND ACCURETLY AS DESCRIBED ABOVE BY PROPER SHIPPING NAME AND ARE CLASSIFIED,PACKAGED,MARKED AND LABELED,AND ARE IN ALL ASPECTS IN PROPER CONOWN FOR <br /> FREE OF ANY HAZARDOUS,MERCURY UNPROTECTED NEEDLES AS DEFINED BY THE US CODE OF FEDERAL REGULATIONS AND/OR APPROPRIATE KATE RULES <br /> TRANSPORT ACCORDING TO APPLICABLE FEDERAL AND STATE REGULATIONS.I ALSO FURTHER DELARE THAT THIS SHIPMENT OF WASTE IS <br /> AND REGULATIONS. <br /> Customer Name X Date Wednesday,August 21,2013^ <br /> Generator Signature: <br /> Ple n Full Name <br /> Please Prin Fu arae <br /> Transfer Drivery - DBte Wednesday,August 21,2013 <br /> Route Driver: Signature /� <br /> Please 11 Name <br /> JkAPlease Print Full Name <br /> Transfer Station: Transfer Station X e Date <br /> Please Print Full Name Please Sign Full Nam <br /> All Chem(Sterlcycle) Alternative Designated Facility Treatment Center(Incineration) <br /> Transfer Station Permit#TS/OST-SS Permit#ITF-0203 a EPA#CAL000344393 <br /> Transport Permit#4707'EPA#CAL000344393 Permit# EPA Permit# EPA <br /> Stericycle,Inc. Waste Management Daniels Sharpsmart,Inc. <br /> Daniels Sharpsmart,Inc. 4144 E.Therese Ave. <br /> 3668 Enterprise 21 Great Oaks Boulevard 3670 Enterprise Ave <br /> Hayward,CA 94545 (559)834-6252 SanJose,CA 95119 (408)363-1660 <br /> Hayward,CA 94545 (760)489-5009 Fresno,CA 93725 (559)834-6252 <br />